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A human case study details a 52-year-old male undergoing elective total right knee arthroplasty for advanced osteoarthritis. It includes the patient's history of present illness, past medical and surgical history, medications, allergies, social and family history, and a review of systems. Physical examination findings, primary diagnosis, and the planned procedure are outlined. The document also covers the assessment, diagnosis, and a treatment plan, including surgical intervention, perioperative management, postoperative care, medications, and follow-up. This case study is valuable for medical students and healthcare professionals seeking to understand the management of patients undergoing knee arthroplasty. It highlights conservative management, surgical intervention, and postoperative rehabilitation in improving patient outcomes.
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Elective Total Right Knee Arthroplasty for Advanced Osteoarthritis
Hospital Admission Class : This could refer to the type of admission:
Elective (which applies here) — scheduled, non-emergency procedure. Emergency or Urgent — typically not applicable in this case.
✅ Class : Elective Admission
Medical Coding/Class Number (e.g., ICD/CPT) : For documentation or billing purposes:
ICD-10 Code for osteoarthritis of the right knee: M17. CPT Code for total knee arthroplasty: 27447
Ward or Room Class : Some hospitals assign patients to different classes (e.g., Class A, B, C) based on amenities or insurance, but this info isn't provided in the image.
Patient Name : Robert Jones Age : 52 years Sex : Male Date of Admission : [Insert date] Admitting Physician : [Insert provider name]
Chief Complaint : Right knee pain due to osteoarthritis.
History of Present Illness : Mr. Robert Jones is a 52-year-old male presenting for elective total right knee arthroplasty. He has a long-standing history of right knee osteoarthritis, which has progressively worsened over the past several years. Conservative management, including physical therapy, NSAIDs, and corticosteroid injections, has failed to provide lasting relief. The patient reports increasing difficulty with ambulation and activities of daily living due to pain and limited range of motion.
Past Medical History :
Osteoarthritis (Right Knee) Hypertension (well controlled) Hyperlipidemia
Physical Examination
General : Alert and oriented x3. In no acute distress. Well-nourished and cooperative.
Vital Signs :
BP: 128/78 mmHg HR: 76 bpm RR: 16 breaths/min Temp: 36.8°C SpO₂: 98% on room air
HEENT : Normocephalic, atraumatic. Pupils equal, round, and reactive to light. No oral lesions or pharyngeal erythema.
Cardiovascular : Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses 2+ and symmetric.
Respiratory : Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Abdomen : Soft, non-tender, non-distended. No organomegaly or masses. Bowel sounds present.
Musculoskeletal :
Right knee : Swelling and bony deformity present. Reduced range of motion. Tenderness on palpation along medial and lateral joint lines. Crepitus noted with movement. No signs of infection. Left knee : No swelling or tenderness. Full range of motion. No other joint deformities. No evidence of trauma.
Neurological : Alert and oriented. Cranial nerves II–XII intact. Sensation intact to light touch in all extremities. Strength 5/5 in upper and left lower extremities. Right lower extremity strength limited by pain.
Skin : Intact, no rashes, ulcers, or lesions. No signs of infection at joints.
Key Findings
Primary Diagnosis : Advanced osteoarthritis of the right knee Reason for Admission : Elective total right knee arthroplasty Symptoms : o Chronic right knee pain o Decreased range of motion o Functional limitations affecting daily activities Physical Exam : o Swelling and crepitus in right knee o Tenderness along joint lines o Limited range of motion and strength in the right lower extremity due to pain Imaging/Studies (assumed but typical for this case): o X-ray: Degenerative changes in right knee joint space Medical History : o Hypertension, hyperlipidemia, osteoarthritis Failed Conservative Treatment : o NSAIDs, physical therapy, intra-articular injections
Diagnosis
Primary Diagnosis : o Right knee osteoarthritis , advanced stage — ICD-10: M17. Planned Procedure : o Elective total right knee arthroplasty — CPT: 27447
History of Present Illness (HPI)
Mr. Robert Jones is a 52-year-old male with a several-year history of progressively worsening right knee osteoarthritis. He reports increasing pain, stiffness, and reduced mobility in the right knee, particularly with walking, climbing stairs, and prolonged standing. These symptoms have resulted in significant impairment of his daily activities and occupational function as a construction supervisor.
He has undergone extensive conservative treatment, including:
Oral NSAIDs Physical therapy Corticosteroid injections
Despite these measures, his symptoms have persisted and worsened over time. Imaging studies have confirmed advanced degenerative changes in the right knee joint. After discussion of risks, benefits, and alternatives, he has elected to proceed with total right knee arthroplasty.
Treatment Plan
